Advanced Diagnostic Imaging (ADI)

Transcription

1 Advanced Diagnostic Imaging (ADI)

2 eqhealth Solutions 2

3 Overview of eqsuite» 24/7 accessibility to submit review requests to eqhealth via web.» Secure transmission protocols that are HIPPA security compliant.» System access control for changing or adding authorized users.» A reporting module that allows hospitals to obtain real-time status of all reviews.» Rules-driven functionality and system edits to assist Providers through immediate alerts such as when a review is not required or a field requires information.» A helpline module for Providers to submit queries.» Electronic submission of additional information needed to complete a review request. 3

4 Who Can Access eqsuite?» New Users: Register for a Web Account Some organizations may already have an assigned eqhealth System Administrator. This person is responsible for creating user IDs and assigning access rights to eqsuite for those who need to put in PARs. If an organization does not have a System Administrator, a Provider Access form needs to be submitted with a System Administrator assigned.» Existing Web Account Log into eqsuite using your existing username and password. o Your username and password are unique to your organization. o If your organization needs to add an additional user account the System Administrator would be responsible for adding/inactivating user accounts. Note: You can locate the Provider Access form via our website FL.EQHS.ORG Access forms can be faxed or ed to Provideroutreach@eqhs.org

5 Recipient Requirements Recipients must be: Enrolled in a Medicaid benefit program that covers the services: Fee-for-Service Dually eligible recipients Medicare/Medicaid Commercial/Medicaid Eligible at the time services are rendered* Note: Medically Needy recipients must have active eligibility on the date of service. The date of service and the dates on the PA must be included in the eligibility span. 5

6 Requests Not Reviewed by eqhealth Recipients who are: Members of a Medicaid Managed Medical Assistance (MMA) Recipients enrolled in MMA must have authorization from their managed care plan. Not Medicaid eligible, but have other coverage for radiology services through a third party liability source such as: Medicare Commercial insurance 6

7 Who can submit authorization requests? Prior Authorization Retrospective Ordering physician MD/DO PA ARNP Dentist Podiatrist Chiropractor Rendering Provider/Reading Radiologist Hospital ASC Physician Independent Lab 7

8 Required Documentation Required Documentation A signed physician order Electronic signature is acceptable as long as the signature states electronically signed. 8

9 Completion Timeframes Initial Request Submission Review Completion Timeframes Routine requests Prior authorization Timeframe begins upon receipt of all required documentation Approved at nurse review - within 1 business day Referral to second level reviewwithin 3 business days Retrospective Reviews Reconsideration review Within one year of the retroactive eligibility determination Within 10 business days of the denial notice Within 20 business days Within 3 business days of receipt of the request for reconsideration. 9

10 Review Process 1 st Level review 2 nd Level Review Nurses conduct 1 st Level reviews. They check to make sure required administrative criteria are present and assess clinical information for Medical Necessity. 1 st Level reviewers can approve a request, pend a request for more information or refer a review to 2 nd Level review. 2 nd Level Reviewers are physicians. They can approve, pend, partially or fully deny services. Partial and full denials based on medical necessity are ONLY done by 2 nd level reviewers according to Florida law Partial and full denials have Reconsideration (Recon) and Fair Hearing rights. Recipients or their parent/legal guardian need to be aware of this Due Process. There are time limitations for requests which are outlined in the denial letters. 10

11 Modifications to an Existing Review Type Method Timeframe Extension of authorization time frame Providers can extend for an additional 30 days, using the eqsuite utility. Only one 30 day extension may be submitted. N/A Change of facility Upcoding/downcoding Submit on-line helpline ticket Or contact Customer Service Call Customer Service Within 2 business days 11

12 Upcoding/Downcoding When the prior authorized code requires. The following process is followed Upcoding: e.g. the code for no contrast was originally approved and contrast was used A new review determination IS required. The provider will: o Contact eqhealth s Customer Service line or submit an online helpline request to cancel the existing authorization. o Enter a new review request with documentation to substantiate the medical necessity for the study that was performed Downcoding: e.g. the code for with contrast was originally approved and contrast was not used A new review determination is NOT required. The provider will: o Contact eqhealth s Customer Service line or submit an online helpline request to change in the code. 12

13 Things to remember If you are a physicians office you must enter the rendering/billing providers Medicaid ID# in the Provider ID You can only select Urgent as the request type if the test is scheduled for the same day. Always check the box that states Reading Radiologist will bill separately The PA number will be available 24-48hrs after the approval has been given. 13

14 Live Demonstration 14

15 Provider Communication Dedicated Florida Website: Web: FL.EQHS.ORG Customer Service: Ph: Monday-Friday Hours:8 a.m.-5 p.m. (Except Florida state holidays) Provider Outreach:

16 Questions? 16